Quiz

Oral Cancer: A Self-Assessment Quiz

Sol Silverman, Jr., MA, DDS, and Raymond J. Melrose, DDS

Copyright 2001 Journal of the California Dental Association.

This article consists of a quiz on oral cancer knowledge. The goals of the quiz are to reinforce known cancer information and present new information. Photographs are used to bring a sense of the practical problems that clinical pathology presents. Also, a number of real-life case situations are presented with their corresponding illustrations so that the readers may use their clinical judgment and experience in choosing an answer.

The answer key can be found here.

The authors have developed a new and updated iteration of the "Oral Cancer Quiz" that was published in this journal in March 1982 and rewritten and published again in this journal in October 1991. This version is shorter, more profusely illustrated, and divided into five key sections.

The goals of the oral cancer quiz remain the same as those of the earlier versions. The authors wish to reinforce known cancer information and present new information in an intellectually stimulating way. The photographs from the collection of the primary author are used to visually enhance the material and bring a sense of the "real life" practical problems that clinical pathology presents. Also, a number of real-life case situations are presented with their corresponding illustrations so that the readers may use their clinical judgment and experience in choosing an answer. The answers to the quiz are published elsewhere in this issue. It is suggested that readers take the quiz in small increments over several days rather than try to digest the quantity of material in one sitting.

Oral cancer remains a hugely significant problem not just in California, but also worldwide. Dentists are the principal health care practitioners responsible for educating patients about risk factors for oral cancer; for routinely conducting oral cancer detection examinations on their patients; for detecting abnormalities; for taking appropriate, timely actions to obtain a diagnosis of abnormalities detected; and for assisting in the management of patients who have been treated for oral cancer or other malignancies involving the head and neck region. No profession is better-trained for the assumption of these responsibilities, and only dentistry will be held publicly accountable if it fails as a profession to fulfill them.

Authors

Sol Silverman, Jr., MA, DDS, is a professor of oral medicine at the University of California at San Francisco School of Dentistry

Raymond J. Melrose, DDS, is a professor in and the chairman of the Department of Oral and Maxillofacial Pathology at the University of Southern California School of Dentistry. He is also president-elect of the California Division of the American Cancer Society.

To request a printed copy of this article, please contact/Sol Silverman, Jr., MA, DDS, UCSF School of Dentistry, 707 Parnassus Ave., Box 0422, San Francisco, CA 94143.

Oral Cancer Quiz

Sections

A: Epidemiology/Biology

B: Etiology/Prevention

C: Precancer

D: Early Detection/Diagnosis

E: Treatment/Complications

Section A: Epidemiology/Biology

1. The leading causes of death of adults in the United States may be ranked in order as follows:

a. Cancer, heart disease, accidents.

b. Heart disease, accidents, cancer.

c. Heart disease, cancer, accidents.

d. Alcoholism, heart disease, cancer.

2. Which of the following sites is at the highest risk for developing cancer?

a. Tongue

b. Floor of mouth

c. Soft palate

d. Lip

3. The most common form of oral cancer is:

a. Lymphoma.

b. Squamous cell carcinoma.

c. Basal cell carcinoma.

d. Adenocarcinoma.

4. Data on racial characteristics and occurrence of oral cancer indicate that:

a. Environment and habits play a small role in etiology.

b. Inheritance has been shown to play a major role.

c. There are no ethnic differences.

d. Familial tendencies are not apparent in oral cancer.

5. Once a patient has had one primary oral cancer:

a. There is almost no risk of developing a second head and neck cancer.

b. More than 15 percent of patients will develop a second head and neck cancer.

c. Little can be learned about second oral cancers since about 50 percent of the patients die within five years of diagnosis/treatment.

d. An immunity is developed against subsequent head and neck cancers.

6. Of all oral cancers, squamous cell carcinoma accounts for approximately:

a. 20 percent.

b. 50 percent.

c. 70 percent.

d. 90 percent.

7. Carcinoma and sarcoma are different by virtue of:

a. Tissue of origin.

b. Histologic grading.

c. Growth rate.

d. Signs and symptoms.

8. Current data on the relative frequency of oral cancer in men and women indicate that:

a. Estrogen definitely offers tissue resistance or protection.

b. Habits and environment may be the most important factors.

c. In those over 40, men should be more closely examined for oral lesions than women.

d. Inheritance is the most important factor.

9. Lip cancers:

a. Are decreasing in incidence yearly.

b. Are not related to sun exposure.

c. Have a poorer prognosis than most oral cancers.

d. Are related to herpes simplex virus infections.

10. The most common mode(s) of oral carcinoma spread is/are by:

a. Blood vessel and direct invasion.

b. Direct invasion and lymphatics.

c. Lymphatics only.

d. Blood vessels only.

11. Induration refers to:

a. Redness.

b. Hardness.

c. Swelling.

d. Painfulness.

12. Patient prognosis for oral squamous cell carcinoma appears to be most dependent upon:

a. Tumor stage and early treatment.

b. Combining radiation and surgery.

c. The addition of chemotherapy to radiation and/or surgery.

d. The patient’s age and gender.

13. Most important for reducing morbidity and mortality from an oral cancer is:

a. Combination treatment involving surgery, radiation, and chemotherapy.

b. Optimal nutrition.

c. Discontinuation of all tobacco habits.

d. Early detection.

Section B: Etiology/Prevention

14. This 22-year-old male patient has used snuff daily for four years. He was referred by his dentist. He is in good health and takes no medications.

a. There is an extremely high risk for developing a carcinoma within 10 years.

b. The primary carcinogen in smokeless tobacco consists of nitrosoamines.

c. There are no sugars in smokeless tobacco, thus no risk for caries.

d. There is so little nicotine in smokeless tobacco that habituation and/or addiction are

unimportant factors.

15. Which of the following statements is true?

a. Most oral cancer patients smoke cigars.

b. Tobacco contains nicotine, which is the main carcinogen.

c. The main carcinogen is carbon monoxide.

d. Tobacco can induce abnormal epithelial cell changes.

16. Which forms of tobacco are associated with increased risk of oral cancer development?

1. Filtered cigarettes

2. Unfiltered cigarettes

3. Cigars and pipes

4. Snuff and chewing tobacco

a. Only 2 and 3 are correct.

b. Only 2 and 4 are correct.

c. Only 1, 2, and 3 are correct.

d. All are correct.

17. Which of the following demonstrates little or no association with oral cancer?

a. Advancing age

b. Dental prostheses

c. Leukoplakia

d. Diets low in fruits and vegetables

18. Which statement about the use of smokeless tobacco is correct?

a. It is a safe alternative to smoking.

b. It delivers a rapidly absorbed dose of nicotine.

c. It is not habituating.

d. Long-term use is not associated with an increased risk for oral cancer.

19. Which of the following smoking cessation techniques/methods has no validity?

a. Transdermal nicotine patches to increase nicotine blood levels to help break tobacco smoking habituation/addiction

b. Group psychology sessions to help break the smoking habit

c. Hyperbaric oxygen treatments to reduce tobacco-related carbon monoxide blood levels

d. Use of a chewing gum containing nicotine to reduce the urge to smoke

20. Human papillomaviruses can occur in oral epithelium. They are LEAST associated with:

a. Geographic tongue (glossitis migrans).

b. Oral condyloma (warts).

c. Oral squamous cell carcinoma.

d. Oral leukoplakia.

21. The main difference between severe dysplasia/carcinoma in situ and carcinoma is based on histologic evidence of:

a. Invasion of connective tissue.

b. Mitotic activity.

c. Nuclear/cytoplasmic ratio.

d. Degree of differentiation.

22. Epithelial dysplasia refers to:

a. A discrepancy in cellular maturation with an increased risk for malignant transformation.

b. An abnormality of keratin (dyskeratosis).

c. Tissue changes with a certainty to transform to carcinoma.

d. A well-defined clinical entity with rigid, well-described, and reproducible criteria.

23. Squamous carcinoma of the mandibular gingiva developed in a patient who has worn a

partial denture for many years. A cause-and-effect relationship between removable dentures and oral cancer is not clear because:

1. Denture materials are noncarcinogenic by accepted testing methods.

2. Gingiva is an infrequent site of oral cancer, accounting for less than 6 percent of oral cancers.

3. In epidemiologic studies, there have been no statistically significant correlations between prosthetic appliances and sites of oral cancer.

4. Gingival cancers occur only in areas of denture irritation.

a. Only 1, 2, and 3 are true.

b. Only 2, 3, and 4 are true.

d. Only 1, 3, and 4 are true.

d. All are true.

Section C: Precancer

24. This 40-year-old woman has smoked from one to two packs of cigarettes daily for about 15 years. She has mild hypertension and diet-controlled adult-onset diabetes. She takes birth-control pills and occasional Tylenol for headaches and "arthritis." The lesion was biopsied six months ago and signed out as a benign focal keratosis without evidence of cellular atypia or dysplasia. The patient’s chief complaint at this visit was a recent slight discomfort/irritation at the lesion site that has persisted for about one month. There were no areas of induration or palpable lymph nodes. The next most appropriate step would be:

a. To have the patient go on a three-month smoking-cessation program to see if the lesion disappears.

b. To perform an incisional biopsy even though there was a negative biopsy six months ago.

c. To have the patient return in four to six weeks to determine if there is a change in signs or symptoms.

d. To check the patient’s blood sugar, since poor glycemic control can aggravate leukoplakia.

25. Palatal papillary hyperplasia:

1. Is premalignant.

2. Is not premalignant.

3. Is generally considered to be an allergic reaction.

4. May be biopsied and/or followed periodically.

a. Only 1 and 4 are correct.

b. Only 2 and 3 are correct.

c. Only 2 and 4 are correct.

d. Only 1 and 3 are correct.

26. This patient has the erosive form of lichen planus. This lesion:

a. Is premalignant with a high risk for malignant transformation.

b. Appears to be associated with some increase in risk for oral cancer.

c. Will often undergo spontaneous remission.

d. Should be surgically removed.

27. The cause of lichen planus is:

a. The human papillomavirus.

b. Nutritional deficiency.

c. Tobacco-induced.

d. Probably immunopathic (i.e., autoimmune).

28. Clinical leukoplakia is usually a manifestation of which histologic change?

a. Hyperplasia

b. Dysplasia

c. Hyperkeratosis

d. Atrophy

29. This patient manifests a clinical leukoplakia of the lateral tongue.

a. This always represents an epithelial response to a well-defined irritant.

b. This lesion could represent microscopic epithelial dysplasia.

c. Surgical removal will prevent recurrence.

d. Tobacco plays no role.

30. A clinical leukoplakia involving the buccal mucosa, gingiva and oropharynx persists despite removing all identifiable irritants. Brush biopsy, toluidine blue staining and several representative incisional biopsies show no evidence of dysplasia or malignancy. This leukoplakia then:

a. Is not premalignant.

b. Must still be considered to have a risk for malignant transformation.

c. Need not be observed any further.

d. Should be automatically biopsied every six months.

31. The above leukoplakia is best managed by:

a. Avoiding laser vaporization because of the risk of inducing carcinogenesis.

b. Excision and skin grafting.

c. Intensive vitamin A therapy.

d. Periodic follow-up with incisional rebiopsy if there is a change in signs and/or symptoms.

32. The prognosis for leukoplakia worsens if there is:

1. Microscopic dysplasia.

2. A red (erythematous) component.

3. Evidence of proliferation and a verrucous appearance.

a. Only 1 and 2 are correct.

b. Only 1 and 3 are correct.

c. Only 2 and 3 are correct.

d. All the above are correct.

33. A red component (erythema) in a leukoplakic lesion indicates an increased risk for:

a. Infection.

b. Allergy or hypersensitivity.

c. Dysplasia.

d. Immune deficiency.

34. Oral hairy leukoplakia is:

a. Associated with the human immunodeficiency virus (HIV).

b. Usually caused by candidal overgrowth.

c. A form of lichen planus.

d. Associated with a premalignant risk.

35. This proliferative verrucous leukoplakia occurred in a female nonsmoker:

a. It is not likely to transform into carcinoma because she is a nonsmoker.

b. Chances are about 50 percent that it will eventually disappear.

c. It is probably related to a herpes family virus.

d. It could be associated with a type of human papillomavirus.

36. Vitamin A or its precursors (carotenoids):

a. Are predictably effective as a means of controlling leukoplakia.

b. Play an important role in epithelial keratinization, although the exact biochemical mechanism is unknown.

c. Are not toxic to humans even in high dosages.

d. Are effective pro-oxidants.

37. This 50-year-old woman has had an area of leukoplakia on the buccal mucosa for about a decade. It is asymptomatic and has not shown any changes since the original biopsy (patient and dentist observations). The patient has good hygiene and no other mucosal lesions. She has not smoked for more than 15 years, only drinks socially, is in good health, and takes no medications.

a. This more than likely would show areas of moderate dysplasia upon biopsy because of the long duration.

b. Even if a biopsy would show no dysplasia or carcinoma, there would be a need for periodic follow-up examinations.

c. Since there is no red component, one would not find any epithelial dysplasia.

d. The most effective management would be chemoprevention rather than laser removal.

Section D: Early Detection/Diagnosis

38. Staging of an oral cancer depends upon:

a. Tumor differentiation.

b. Size and spread.

c. Location.

d. Immune status.

39. A palpable neck (cervical) lymph node in a patient with an oral cancer:

a. Indicates an advanced cancer.

b. Has no relation to prognosis.

c. Does not influence treatment.

d. Indicates that an incisional biopsy should be done for evaluation.

40. A swelling in the head and neck thought to be associated with a lymph node should be evaluated initially by:

a. Incisional biopsy

b. Excisional biopsy

c. Brush biopsy

d. Fine-needle aspiration biopsy

41. This 55-year-old woman has noticed this painful tongue lesion for more than three months. It does not seem to be getting any worse, but it is no better. She doesn’t smoke or use alcohol. She has diet-controlled diabetes and mild hypertension. Outside of her tongue discomfort, she feels fine. The differential diagnosis includes carcinoma, dysplasia, infection, and vesiculoerosive disease.

a. Most probably, her blood sugar is out of control; and she should be referred to her physician for a complete work-up.

b. As the first step, she should immediately be put on a three-week course of antibiotic and anti-inflammatory drugs.

c. An incisional biopsy should be performed, since this is an effective way to rule out dysplasia and carcinoma.

d. A biopsy should definitely be delayed in order to first learn more about her medical status.

42. This 48-year-old woman has a rubbery-firm swelling of the #30 buccal gingival area. It is uncomfortable, and has been bothersome for about three weeks. A periapical X-ray shows an irregular loss of alveolar bone in that area. The oral hygiene is excellent, and a full mouth X-ray survey one year ago shows minimal evidence of periodontal disease. There has only been a minimal response to a 10-day course of antibiotics. Tooth #30 is moderately mobile. The next step should be:

a. Extract #30

b. Switch antibiotics and institute aggressive curettage

c. Biopsy the swelling

d. Start endodontic treatment on #30

43. This patient has been referred because of concern regarding an asymptomatic discoloration in the left floor of mouth. While the duration is uncertain, it "seems to be getting a little darker in color." The area is soft, and there are no palpable lymph nodes. There are no other oral lesions. She takes thyroid and hormone supplements and an antacid for regurgitation. She smokes and drinks moderately.

a. Because of the dark color and uncertain history, this pigmentation almost certainly represents a malignant melanoma.

b. An incisional biopsy would significantly spread malignant cells if this were a melanoma, as well as markedly worsen the prognosis.

c. Racial melanosis is the most logical explanation.

d. An incisional biopsy would be a better choice than periodic observations.

44. This lesion is thought to be either a benign or malignant tumor of minor salivary gland origin. The most appropriate diagnostic technique would be:

a. Fine-needle aspiration biopsy.

b. Incisional biopsy.

c. Excisional biopsy.

d. MRI or CT imaging.

45. This soft, sessile, asymptomatic mass has been noticed for about one year. The patient bites it occasionally, and there has been a minimal increase in size. The most likely diagnosis is:

a. Fibroma.

b. Benign mixed tumor.

c. Squamous cell carcinoma.

d. Lymphoma.

46. These asymptomatic tissue proliferations or lobules at the lateral border of the oral tongue represent:

a. Traumatic fibro-epithelial hyperplasia.

b. Premalignant mucosal changes.

c. Foliate papillae.

d. Fungiform papillae.

47. Purpura is a clinical manifestation of:

a. Bleeding.

b. Leukemic infiltrates.

c. Anemia.

d. Melanin deposition.

48. A complete blood count is LEAST useful in establishing a diagnosis or assessment of:

a. Leukemia.

b. Anemia.

c. Leukopenia.

d. Carcinoma.

49. The erythematous denture-bearing mucosa has been painful for one month. The 65-year-old patient has had these dentures for more than 10 years. She complains of a slight dryness but otherwise seems to be in good health. The most likely diagnosis of this condition is:

a. Epithelial dysplasia.

b. Candidiasis.

c. Nutritional deficiency.

d. Allergy to denture materials.

50. This patient is suspected as having a malignant melanoma.

a. Melanoma is a common oral cancer.

b. Oral melanomas are associated with smoking.

c. Oral melanoma has a poor prognosis, with less than 10 percent surviving five years.

d. Suspected oral melanomas should not be biopsied because of the risk of metastasis.

51. Fine-needle aspiration biopsy:

a. Is dangerous because it may spread tumor cells.

b. Cannot differentiate between benign and malignant cells.

c. Is useful in assessing potential malignancies of major salivary glands.

d. Is usually very painful and requires anesthesia.

52. This patient presents complaining of a lump in the neck noticed for about four months. It is slightly uncomfortable and is slowly increasing in size. Which of the following statements is correct?

a. This may represent a metastatic tumor with an oral, oropharyngeal, or nasopharyngeal primary.

b. This most likely represents a dental infection.

c. A fine-needle aspiration biopsy would not yield any useful information.

d. An incision and drainage procedure should be attempted immediately.

53. This HIV-positive patient has developed Kaposi’s sarcoma of the gingiva. Which statement about Kaposi’s sarcoma is INCORRECT?

a. The palate is the most frequent oral location.

b. Kaposi’s sarcoma is vascular and should not be biopsied.

c. Although most commonly a disease of the facial skin, Kaposi’s sarcoma can occur first in the mouth.

d. Kaposi’s sarcoma is associated with the herpes simplex virus, type 8.

Section E: Treatment/Complications

54. A 60-year-old woman is referred with complaints of a sore in her mouth that has been present for more than two months. The biopsy and history document that this is a rapidly growing exophytic, well-differentiated squamous cell carcinoma with no X-ray evidence of bone invasion. The tumor board recommends that external beam radiation therapy alone (approximately 7000 cGy in six to seven weeks) can control this cancer and that the prognosis is good. The patient is otherwise in good health.

a. The lower right molar should be extracted immediately, even though it might delay therapy about one week.

b. The patient should be maintained on antibiotics to avoid dental infection and start radiation immediately, since there is little risk for osteoradionecrosis.

c. Radiation therapy should be started immediately and the molar extracted immediately after radiation is completed.

d. An attempt to delay extraction of the molar for six months should be made, since extraction is much safer then.

55. This patient with chronic leukemia has just finished a course of cytotoxic drugs as a monthly regimen of chemotherapy to control the blood dyscrasia. She has two complaints: a sore tongue and dental pain with swelling from a periapical abscess in a periodontally involved tooth.

1. The patient should be put on antibiotics immediately.

2. A molar extraction should be considered when the white blood cells are at or near normal levels.

3. The tongue changes probably represent a mucositis secondary to the cytotoxic drugs.

a. Only 1 and 2 are correct.

b. Only 1 and 3 are correct.

c. Only 2 and 3 are correct.

d. All are correct.

56. This patient has persistent breast cancer. She has just completed an intensive seven-day conditioning regimen of cytotoxic drugs preliminary to a stem-cell transplant (the latter to reconstitute her destroyed white blood cells). The gingival findings are most likely a reflection of:

a. Leukopenia.

b. Thrombocytopenia.

c. Infection.

d. Metastatic cancer.

57. This 82-year-old woman has noticed this asymptomatic, indurated lesion on her lower lip for about five weeks. There are no palpable cervical lymph nodes. She doesn’t smoke or drink and generally feels quite well. Her hypertension is under control with diet, diuretics, and mild exercise. She has a history of breast cancer treated by surgery four years ago without evidence of local recurrence.

a. This most likely is a metastasis from her breast cancer that was inadequately controlled by surgery.

b. This probably is a persistent herpes labialis that requires topical antiviral medications.

c. An incisional biopsy is the most appropriate next step.

d. Institute topical anti-inflammatory agents.

58. Hyperbaric oxygen treatments have been useful in some cancer patients for the management of osteoradionecrosis resulting from radiation effects on bone because:

a. High concentrations of oxygen kills cancer cells.

b. Hyperbaric oxygen stimulates the formation of blood vessels (angiogenesis).

c. Hyperbaric oxygen attracts white blood cells to necrotic areas by chemotaxis.

d. Hyperbaric oxygen doesn’t require any surgery.

59. A patient with a non-Hodgkin’s lymphoma is receiving monthly chemotherapy to control the disease. An extraction of a periodontally involved molar is planned. The patient might combat a post-extraction bacteremia poorly because of potential:

a. Leukopenia.

b. Thrombocytopenia.

c. Poikilocytosis.

d. Leukocytosis.

60. In oral cancer patients with healthy teeth and gingiva who are to be treated by radiation, the dentition should be managed by:

a. Extracting all teeth in the primary beam of radiation before therapy begins.

b. Restoring all teeth in the primary beam of radiation with crowns.

c. Instituting optimal hygiene, home care, and fluoride applications.

d. Replace all metal fillings with composites.

61. In patients who have completed radiation therapy for oral cancer:

a. Dentures can never be worn again because of the risk for developing osteoradionecrosis.

b. Dentures cannot be worn for six months.

c. Properly fitting dentures can usually be worn without a high risk for developing osteoradionecrosis.

d. Special soft liners must be used if dentures are to be worn.

62. The most critical variable influencing the lack of complications following tooth extraction in patients who have been irradiated for oral cancer is:

a. Stage of the primary tumor.

b. Total radiation dose to bone.

c. Post-treatment timing of the extraction.

d. Surgical technique.

63. Post-radiation and post-surgical trismus are both best managed by:

a. Daily exercise of the muscles of mastication.

b. Immobilization.

c. Cortisone injections.

d. Surgical intervention.

64. Therapeutic radiation for oral cancer may directly and/or indirectly cause:

1. Hyposalivation and xerostomia.

2. Bone marrow fibrosis and avascularity.

3. Altered taste.

4. Dental caries.

a. Only 1, 2, and 3 are true.

b. Only 2, 3, and 4 are true.

c. Only 1, 3, and 4 are true.

d. All are true.

65. This patient received 7,200 cGy radiation for a carcinoma of the base of the tongue one year ago. He has had no dental care for the past five years. Aside from the carious teeth, full-mouth X-rays reveal a bone pattern that appears to be within normal limits. The bone in the primary beam of radiation:

a. Is probably normal and at no risk for osteoradionecrosis.

b. Is probably abnormal and at some risk for osteoradionecrosis.

c. Can never support a prosthetic appliance if the teeth were extracted.

d. Would not respond well to endodontia.

66. The development of osteoradionecrosis is most closely related to:

a. Character of the oral bacterial flora.

b. Xerostomia.

c. Pre-radiation extractions.

d. Radiation dose to bone.

67. The development of dental caries in post-irradiated oral cancer patients is most closely related to:

a. Xerostomia.

b. The direct effect of radiation dose to teeth.

c. Altered vascular supply.

d. Pulpal damage.

68. The greatest danger that invasive dental care presents to leukemic patients is:

a. Infection.

b. Hemorrhage.

c. Severe pain.

d. Blast crisis.

69. In the management of leukoplakia:

a. The carbon dioxide laser has been effective.

b. Most should be excised and skin grafted.

c. It responds well to vitamin A.

d. It responds well to corticosteroids.

70. This 30-year-old man is referred because of a slightly painful sore on the left lateral tongue that has been noticed for about four weeks. He does not smoke or drink alcohol, he has no other risk factors, takes no medicines, and is in good health. He has had occasional canker sores (recurrent aphthae) in the past. Because of some induration and the fact that the lesion has been present for about a month, the differential diagnosis includes dysplasia and squamous carcinoma.

a. Best managed by observation and palliation since the patient has no risk factors for cancer

b. Best managed with systemic or topical corticosteroids for unusual aphthous ulcer

c. Best managed by an excisional biopsy

d. Best managed by an incisional biopsy

The answer key can be found here.